Roadmap for Managing Pain

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ROADMAP FORMANAGING

PAIN

PASSP RTto well-beingempowering people with bleeding disorders

to maximize their quality of life


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Roadmap forManaging Pain

The Canadian Hemophilia Society (CHS) exists to improve the qualityof life of persons with hemophilia and other inherited bleedingdisorders and to find a cure.

The CHS consults qualified medical professionals before distributingany medical information. However, the CHS does not practice

medicine and under no circumstances recommends particulartreatments for specific individuals. In all cases, it is recommended thatindividuals consult a physician before pursuing any course of treatment.

The CHS would like to acknowledge those people who contributed tothe development ofRoadmap for Managing Pain.

Jenny Aikenhead

Physiotherapist, Alberta Childrens Hospital, Calgary, AB

Maureen Brownlow, RSWIWK Health Centre, Halifax, NS

Nancy Dower, M.D.Walter Mackenzie Health Sciences Centre, Edmonton, AB

Sophia Gocan, R.N.Member, CHS National Programme Committee, Ottawa, ON

Ann Harrington, R.N.St. Michaels Hospital, Toronto, ON

Heather JarmanPharmacist, St. Josephs Health Care, London, ON

D. William C. Johnston, BMedSC, M.D., FRCS(C)Orthopedic Surgeon and Site Medical Director of the University ofAlberta Hospital, Edmonton, AB

Peter Leung, M.D.Pain Management Service, St. Michaels Hospital, Toronto, ON

Pam Wilton, R.N.Vice-President, Canadian Hemophilia Society

Clare Cecchini

Program Coordinator, Canadian Hemophilia Society

David Page

Blood Safety Coordinator, Canadian Hemophilia Society

Supported by Baxter BioScience

For further information please contact:Canadian Hemophilia Society625 President Kennedy Avenue, Suite 505Montreal, Quebec, H3A 1K2Tel: (514) 848-0503Toll Free: 1-800-668-2686E-mail: [email protected]: www.hemophilia.ca

Note: Bleeding disorders affect both men and women.The use of the masculine in this text refers to both.

ISBN 0-920967-50-7


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Table of Contents

Introduction ......................................................2

The impact of pain on the family ......................2

Pain the fifth vital sign....................................4

The role of the comprehensive care team inpain management............................................6

Advocating for better pain management ........7

The use of analgesic..........................................8

Physiotherapy another approach to pain management ........9

Orthopedic and surgical management of pain ..11

Complementary and alternative approachesto pain management ....................................12

Conclusion ......................................................14

Resources ........................................................14


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INTRODUCTION

It is difficult to convey how chronic pain totally invadesand affects all aspects of your life. It is a constantinescapable entity. And it is difficult to make othersunderstand. Everyone has endured pain, but not the kindof pain that you must live with 24 hours a day, 7 days a

week, day and night. - a 50-year-old man with hemophilia

This eloquent statement was made by a person withhemophilia interviewed during an informal survey on theimpact of pain.

It reinforces the message that pain experienced by peoplewith bleeding disorders is not well understood, assessed or

treated. Forty percent of the people interviewed reportedhaving pain all the time. Children also have pain and oftenhave difficulty describing the level of their pain. Many adults,especially those with chronic joint damage, say that pain isthe major element affecting their quality of life. Yet it is onlyrecently that attention is starting to be paid to this seriousproblem.

The most common reasons given for not taking medicationare that pain isnt considered bad enough side-effects are a problem access to a pain specialist is difficult.

The goal of this booklet, Roadmap for Managing Pain, isnot to provide all the answers on pain management. Rather,

it is intended as a guide, showing some of the different routesto take, some of the signposts along the way and, hopefully,destinations which provide some comfort and relief.

Just as importantly, it aims to encourage open discussionof pain and to help people realize that suffering in silence isnot the best way to cope.

THE IMPACT OF PAIN ON THE FAMILY

People who live with hemophiliaand other bleeding disorders areveterans in the acute care of bleeds.They are, however, strangers in theuncharted waters of effective painmanagement. For many years, painhas been seen as an unavoidablepart of the conditionsomething to be suffered, often aloneand in silence.

Often, people are reluctant to complain. They have builtan arsenal of weapons to deal with pain, including doing theirbest to ignore it. There are signs, however well a personhides it, that a person is dealing with pain, for example


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mood changes a reluctance to communicate and interact

with others increased irritability inability to concentrate difficulty sleeping a decreased interest in favourite activities a lack of appetite.

My pain has progressed significantly in the last few years.It has an impact on most aspects of my life. My ability toclimb stairs, walk distances (especially on uneven ground),type at the computer, hammer a nail and open a jar, tomention only some examples, have all been affected.On days when the pain is extreme, it can have a negativeimpact on my mood and it affects those around me.

a 35-year-old man with hemophilia

In the longer term, ineffective pain management may lead to missing school or work missing out on social and family activities feelings of futility and hopelessness.

Pain is an almost invisible presence. Yet it casts a netbeyond the person who is directly affected. In fact, pain hasnever been suffered alone. Family members have always beenaware of the suffering, although limited in their resources todeal with it. They are affected by the pain of a family memberin a number of waysemotionally, socially, academically, finan-cially and spirituallydepending on the family situation of the

person with the bleeding disorder.

When Im in pain, I tend to express it by complainingverballyto tell the truth, by screaming. My familydoesnt like to see me suffer and they do their best tocomfort me and distract me. My mother gives me myNiastase and also morphine for the pain if necessary.

My sister tries to watch TV with me. My father talks to meabout hunting and fishing, which Im crazy about, and weoften look at magazines together.

a 13-year-old boy with a factor IX inhibitor

Families in the bleeding disorder community havedeveloped ways of dealing with the condition by

educating themselves about their particularsituations being open in working with the members of

the comprehensive care teams learning to do home treatments developing internal strengths being creative in dealing with problems

maintaining a sense of hope for the future.These positive coping abilities now need to beapplied to the new frontier of pain management.


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PAIN THE FIFTH VITAL SIGN

Most health care providers and patients are used to havingthe four routine vital signs blood pressure, pulse rate,temperature and respiratory raterecorded at everyassessment. Yet the most common reason for seeking medicalcare is pain. In 1995, the term, fifth vital sign, was coined,suggesting that that pain must be measured and treated.

What then is pain? A medical definition is: Anunpleasant sensory and emotional experience associatedwith actual or potential tissue damage, or described in termsof such damage.

A person with hemophilia, however, describes pain inthese words.

I experience pain daily. It can be mild or severe. It canbe relentless. It can sometimes be unpredictable.I associate my pain with an imaginary companion I like tocall the dragon. This dragon travels with me all day,every day. He makes it his point to remind me when I amdoing something destructive by breathing his heat andmaking me uncomfortable. As I like being active, I would

hate to see the trouble I might get into if I could silencethis dragon completely.- a 35-year-old man with hemophilia

Pain in hemophilia is usually of two types:

Acute pain is usually due to bleeding into joints andmuscles and, more rarely, the after-effects of surgery.

Chronic pain is associated with joint degeneration or otherlong-term complications of hemophilia.

Pain is always subjectiveit is the person with pain whodecides if there is pain or notand always unpleasant. Andit is an emotional experience. When pain becomes chronic,

the actual injury, and even the physiological responses, maynot be visible.

Why assessing and managing pain is so importantThere are many roadblocks to the humane and competent

assessment and management of pain. Patients and health care providers often differ

culturally and socially. Treatment for chronic pain may be unavailable,unaffordable or not covered by health insurance. The variability and unpredictability of pain in peoplewith bleeding disorders may lead to an adversarialrelationship between patients and health care providers.


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Recognizing pain as the fifth vital sign puts assessment atthe forefront, and allows the patient and family to create an

alliance with the health care providers against suffering.The aim of pain control within the first few hours of ableeding episode is relief of suffering. Unrelieved pain canactually interfere with healing and turn acute pain into achronic problem.

With chronic pain control there is the added aim ofmaintaining daily function. The final goal is a balance

between the efficacy of pain relief, the side effects if any,and being as functional as possible.All modalities of pain managementphysical,

pharmacological and psychologicalshould be incorporatedinto the therapeutic plan, if beneficial. Then, there is no fearof the agony of the next episode because the patient canassume control, and knows back-up plans are in place.

Fortunately, there is already a major shift in attitudestoward pain medications. Not so long ago, there was areluctance to prescribe pain killers because they might causeaddiction or interfere with recovery. Research has shown thatthe risk of clinical addiction is overestimated and, in fact,quite rare at the dosages used for pain management. Whatsmore, recovery takes place faster when pain is properly

managed.

How pain is measuredUnlike its vital sign counterparts, there is no gadget to

measure painit must be evaluated by asking questionsand observing behaviour. These are some helpful tools:

For children aged 3 and older, a range of tools is avail-

able for self-reporting and behaviour observation; childrenfrom approximately age 5 are able to reliably complete a

VAS (Visual Analog Scale) score. One useful tool might bethe Face Scales.

Pain has sensory, emotional, motivational, cognitive, andbehavioural dimensions. Hence the individuals subjectiveresponse must override the clinicians bias. Every patientdeserves the most effective treatment, not what the

provider feels he/she should have.


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THE ROLE OF THE COMPREHENSIVE

CARE TEAM IN PAIN MANAGEMENTIn various ways, all of the comprehensive care team

members are involved in the assessment and managementof pain.

The person with the bleeding disorderand, in the caseof a young child, his/her parents, are at the centre of the

process. They need to be able to recognize bleeds earlyand know the difference between pain from acute bleedsand from chronic conditions.

I now know I have to get treatment as soon as possiblewhen I think I am bleeding. Sometimes I think I can getaway without treatment and I wait before telling mymother. This is often how the pain gets very badbut not always.

- an 8-year-old boy with hemophilia

The nurse coordinatorcan ensure that pain is assessedand treated by the appropriate team member. Inmanaging both acute and chronic pain, good bleed diariesare most helpful. So are pain diaries to record preceding

events, intensity of pain, activity level, interventions andresponse to treatment.

The hematologistcan develop a management plan forboth acute and chronic pain which could includemedication. If you do not live close to the HemophiliaTreatment Centre (HTC), your family physician will need tobe involved. In some parts of Canada, HTCs are located in

large health centres, which include pain managementteams whose members have specialized knowledge in themanagement of all aspects of pain.

The physiotherapistcan make various recommendationsfor treating acute or chronic pain. The overall goal is toprevent secondary complications due to pain, such as tightmusculature or poor mobility.

The social workercan help the patient manage the lifecomplications that occur due to pain.

Comprehensive care teams in pediatric and adultcentres often have close working relationships withrheumatologyand orthopedicteams whose expertise canbe called upon to treat pain. Treatments such as jointinjections, synovectomies or joint replacements are someof the options.

People with pain, and their families, need to be awarethat pain is a manageable condition. It doesnt need tobe suffered in silence.Discuss it with yourclinic team and workout a plan that suitsyou.

ADVOCATING


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FOR BETTER PAINMANAGEMENT

My physician told me she never realized how muchpain people with hemophilia had until she went to aCHS workshop on pain management. She couldntbelieve how well her patients hid the pain.

- a 50-year-old man with hemophilia

Advocacy is a process of promoting a cause on behalf ofoneself and/or others. An advocate is someone who worksthrough that process.

You are your own best advocate but, depending on the sit-uation, the role of advocate can be played by almost anyone.

a family memberspouse, parent or sibling

or close friend a nurse, especially the nurse at the HTC a physiotherapist a social worker.

The HTC is part of a network of clinics across Canada andtherefore the comprehensive care team has an established net-work of expertise it can tap into for help in difficult situations.

You may need to seek help from experts in the field of painmanagement. It is sometimes difficult to get a referral to aspecialist because many people, including physicians, simplydo not understand the extent of the pain. In addition to thehematologists at the HTC, a family physician can also facilitatea referral. It is always preferable to have your family physicianand/or your hematologist working with you. So, in all likeli-hood, you will need to convince these people of your need forexpert help.

Fatigue, immobility, frustration and anger are common inpatients with chronic pain, making it difficult to communicate.When pain persists, confidence and respect for health careprofessionals can quickly erode.Effective advocacy can help you communicate competently ina calm, yet assertive way, working with health care providers todevelop an effective pain management plan.

Effective communication strategiesTake a buddy- A family member or a friend who knows yoursituation well can help you to have confidence and to be moreopen about your situation.

Prepare ahead- Write down key points before the visit.Be knowledgeable - Be ready to provide information aboutyour pain. Use resources such as this booklet to know youroptions.

Be proactive - Ask to discuss your pain management. Proposea solution if you think you have one.

Speak up! Be assertive! - State what the problem is and whatconcerns you have. It wont always help to grin and bear it.


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Listen - Listen carefully to what the physician says. Dont beafraid to ask him to explain if youre not sure you understand.

Stay calm - You may feel frustration and impatience becauseof the pain. Staying calm can be difficult, but it is important.

Repeat yourself if necessary- If you find your concerns are notgetting addressed, calmly repeat your problem and insist thatyou are serious about finding a solution.

Be polite and courteous, yet firm - The health care providers

are trying to do their jobs to the best of their abilities, but mayhave little experience treating chronic pain.

Focus on the problem, not the people - You want relief frompainthat is the problem at hand. Focus on finding a solu-tion, and not on any difficulties you are having getting help.

Use I-statements, not you-statements. - Focus on how youfeel and what you need, not on any disputes with health careproviders.

THE USE OF ANALGESIC

I never considered myself one to take drugs

to manage pain, at least not in the obvioussense like taking Tylenol, because I rarely dothis. But I do have a strategy and do in fact take drugsto manage my pain. I infuse with clotting factor on aprophylactic basis to prevent bleeds and thereby preventepisodes of pain. I take Celebrex, not everyday as Ishould, but when I start to feel constant nagging pain

or know that I will be involved in activity the next day.- a 35-year-old man with hemophilia

Most patients with acute pain can obtain relief with thecareful use of common drugs such as acetaminophen(Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs).The new COX-2 inhibitors (Celebrex, Vioxx) have less

effect on platelet function than ibuprofen, which was oftenused for patients as the NSAID of choice. The addition of opi-oids, such as morphine, can increase the control of severepain, depending on the individual patient.

If oral medication is ineffective, intravenous (IV) therapy isan option. Opioids can be given by IV bolus, or by continu-ous administration for even more control.

At the hospital the pain management team put me ona pump so I could administer extra doses of morphinemyself when I felt pain. I didnt have to ask for andwait to get my painkiller. It was also very useful when Istarted to move around again with the help of my phys-iotherapist. I manage my pain and can do my exercises

better. - a 13-year-old boy with a factor IX inhibitor


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Many people worry that opioids are addictive or couldlead to abuse. While there are no guarantees against this,

physicians take all possible precautions. As long as theamount used is for pain, then the chance of addiction isquite low. Short-term use for acute bleeds or surgery isvery unlikely to lead to addiction.

Addiction is not the same as tolerance. When peopleuse opioid pain medication, their bodies become accus-tomed to the dose. One may need to increase the amount

to get the desired effect. Changing to a different medica-tion can sometimes avoid the increase.Poorly treated pain is detrimental to patients. Poor pain

management produces abnormal pain behaviour and mayeven cause patients to seek out street drugs because theyare afraid of not being able to manage severe pain.

Marijuana is probably better to reduce nausea, improve

appetite and promote sleeping. Its use must be individual-ized. For most patients it is not the magic drug. Legalaccess to marijuana is difficult.

When the patient is traveling, the physician can providea specific letter detailing the medications and the amountneeded. He/she may even set out a suggested plan ofmedication for mild and severe bleeds. This will help the

physician in another city to manage the pain. It will alsoprovide evidence at borders that a person is authorized tocarry these medications.

There are many useful medications for controlling pain.In all cases, the type of analgesic and the route of adminis-tration must be tailored to the individual patient. Whatsmore, the underlying health problem must be managed by

knowledgeable health care workers.

PHYSIOTHERAPY ANOTHER

APPROACH TO PAIN MANAGEMENT

The Pain Service at the Hospital for Sick Children always

recommends appropriate exercise to our patients. Weknow that exercise makes the body release chemicals,called endorphins, that not only make us feel less pain,but also make us feel good. Its something you cancontrol and do for yourself.

- Dr. Michael Jeavons, Psychiatrist,Hospital for Sick Childrens Pain Service

An exercise or fitness program improves

Muscle strength - Stronger muscles tire less easily, whichresults in extra support and protection for the joint andreduces the stress and strain that can cause pain.

Joint range of motion - Improved mobility of the joint

results in better alignment of the joint and decreased stresson its surrounding structures. Exercises help reducestiffness and, by improving movement, may alleviate pain.


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Flexibility- Joint contractures and/or muscleshortening may result in pain. These respond

well to stretching exercises. Improved flexibilityalso decreases the chance of muscle bleeds.

Coordination and balance - The developmentof these skills results in a quicker response to asudden movement and a decreased chance offurther injury to the joint.

Confidence and peer acceptance - Exercising

allows sharing with friends. Participation andsuccess bring confidence.

Feelings of well-being and decreased anxiety-Mental stress and anxiety are known to influencesleep patterns, muscle spasm, the frequency ofbleeds and increase sensitivity to pain. Exercisecan decrease feelings of stress.

Release of endorphins - Endorphins are natural chemicalsproduced by the body and act as a damper to thesensation of pain. Their production is thought to beinfluenced by exercise, heat, cold, positive attitude, somephysiotherapy electrical modalities, relaxation andmedications.

Endurance and weight loss - Cardio-vascular exercisesincrease endurance and strength and therefore reducestress on the joints. Weight loss may occur, which alsodecreases pressure on the joint surface.

Sometimes applying ice helps a bit. I have severalorthotics I can use to immobilize the affected joint if

the bleeding is in the joint. I also use crutches or mywheelchair when I have to. Because I had manyhemorrhages, I didnt go to school for a few years.I have been back at school since September 2002 andI love it. I have a lot less bleeding because I am moreactive and my muscles are stronger.

- a 13-year-old boy with a factor IX inhibitor

A physiotherapist at the HTC can assess the pain andassist in choosing an exercise or activity program. Ask thephysiotherapist about these other ways to reduce pain.

Non-electrical treatments such as hot packs, ice,hydrotherapy, splinting, foot orthotics and acupuncture

Electrical modalities such as Transcutaneous Electrical

Nerve Stimulation (T.E.N.S.) and ultra-soundRecommended activities for people who suffer from thepain of arthritis related to hemophilia are those that havelow impact on the joint but allow mobility, strengthening andcardio-vascular exercise. They include:

swimming and aquacise Tai Chi

yoga bicycling walking, dancing, bowling and hiking.


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Road forManaging Pain

For more information, see the Passport to Well-Beingmodule entitled: Destination Fitness.

ORTHOPEDIC AND SURGICAL

MANAGEMENT OF PAIN

Orthopedic interventions can be very effective in managingpain. Acute pain from recurrent bleeding into target joints canbe helped by procedures such as synovectomy. Chronic painfrom an irrevocably damaged joint can be relieved byprocedures such as joint replacement. All invasive proceduresmust be performed under the protection of factorreplacement. The hemophilia doctor must be involved toensure that adequate levels of replacement are provided forthe appropriate time post-operatively. Factor replacementmay be recommended prior to post-operative physiotherapysessions.

Synovectomy

Removal of the swollen synovium (synovectomy) candecrease recurrent bleeding into a target joint and

reduce pain. Three techniques can be used:Radioactive synovectomy- A radioactive isotope isinjected into a target joint. Within the joint, theradioactivity reduces the amount of swollen synovium.

Arthroscopic synovectomy- Using small surgicalincisions a tiny camera is inserted into a joint to guide theremoval of the synovium through the other incisions. This canbe used for ankles, knees and elbows.

Open synovectomy- The joint is opened surgically and thesynovium removed.

Joint replacements

Chronic joint damage produces pain and decreased range

of motion. When the pain is severe and interferes with theactivities of daily living, joint replacement is an option. Kneeand hip replacements are the most common. Elbow, shoulderand ankle replacements are done less commonly due to thecomplexity of the joints.

Before the elbow replacement in 1999, I was in

tremendous pain continuously for a period of about8 months to the point of having to stop working.

a 49-year-old man with hemophilia

The damaged joint and adjacent bone are removed andreplaced with plastic and metal components (knee) or with ametal ball and a plastic cup (hip). Pain control is critical during

the recovery period so that early mobilization and physiothera-py can occur. Most people are left with a pain-free joint.


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Other surgeries

Other surgeries that might be considered to manage pain

from damaged joints are: Removal of small bony growths around the joint margins(cheilectomy)

Fusion of the joint to leave a painless immobile joint(arthrodesis)

Removal of the radial head to improve rotation of theforearm

Removal of the ball part of the femur to allow a fibrousunion to develop. This may be done if a hip replace-ment fails

Removal of a wedge of bone from the femur or tibia torealign the leg and reduce pain (osteotomy).

Less invasive options

Injection of a corticosteroid into an affected joint can beused in the short to medium term to decrease inflammationand pain. This could be used while awaiting surgery.

Ultimately, the operationsreplacements andfusionswere godsends and did relieve the pain. Ido not run or skate and I avoid stairs like the plague,

but my wife and I play golfI still have a sliceandI am able to enjoy travel and visit family and friends.

- a 43-year-old man with hemophilia

COMPLEMENTARY AND ALTERNATIVE

APPROACHES TO PAIN MANAGEMENT

When Im at home, I find that my dog helps me a lotto manage my pain. I see a huge difference since hebecame part of our lives.

- an 8-year-old boy with hemophilia

Complementary and Alternative Health

Care (CAHR) are therapies that areconsidered outside of mainstream medicalpractices.

A complementary therapy, such asaromatherapy to help lessen a personsdiscomfort following surgery, is used togetherwithconventional medicine. In contrast, alternative medicine, such

as a special diet to treat cancer instead of undergoing surgerythat has been recommended by a conventional doctor, is usedin place ofconventional medicine.

While there is scientific evidence supporting some CAHCtherapies, for most there remain unanswered questionsregarding safety and effectiveness. As these therapies

become better understood and validated with sound scientificresearch, some CAHC therapies will become integrated intotraditional medicine.


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Types of complementary and alternative health care therapies

CAHR therapies can be divided into five categories, or

domains: Alternative medical systems including homeopathy,naturopathy, traditional Chinese medicine andAyurveda Mind-body interventions including patientsupport groups, meditation, prayer, biofeedback,humour therapy, and therapies that use creative

outlets such as art, music or dance Biologically-based therapies using substancesfound in nature, such as herbs, foods, andvitamins Manipulative and body-based methodsincluding chiropractic or osteopathic manipulation,reflexology and massage

Energy therapies including qi gong, Reiki andTherapeutic Touch.

The value of complementary and alternative health caretherapies in reducing pain

It is important to ask yourself what you expect from CAHC

therapies. While you may not be able to find relief for yourpain, some CAHC therapies may be able to provide you withindirect benefits.

Consider the potential benefits before starting a treatment.Monitor how you feel as a result of the treatment. Then makea decision about whether to continue it.

The safety of complementary and alternative health caretherapiesTo protect yourself from potential risks involved when usingCAHC therapies, be sure to:

Discuss all of your CAHC practices with your physicianand other health care providers. Ensure the therapy youare considering will be safe when taking into account yourcurrent health status. Try to gather information from sources that look at bothsides of a therapythose who oppose and those whosupport the therapy. Consult publications and web sitesthat stem from governments, recognized medicalorganizations, well-known scientific sources or academicinstitutions. Be cautious about any of the claims that you comeacross. Seek out only fully competent and licensed practitioners.Ask individuals about their training and experience. Checkwith provincial or territorial Ministries of Health.


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Some CAHC products contain powerful pharmacologicalsubstances which can be toxic on their own, or when used

with other medications. Some can affect the ability of yourblood to clot. This is especially dangerous for a person with ableeding disorder. Some substances known to negativelyaffect clotting are

black cohosh cats claw feverfew

garlic ginkgo biloba pau darco.

CONCLUSION

For many, the pain of acute bleeding is the most vividmemory of living with a bleeding disorder. Thanks to bettertreatment, such episodes are much rarer today, but still areality, especially for those with an inhibitor. The long-termconsequences of bleeding, however, mean that many adultsare living with damaged joints andthe burden of chronic pain. For

many years, this pain went largelyunrecognized or was accepted asunavoidable. Today, we know aroadmap for pain managementmust be drawn so that people canfind their way to some relief.

RESOURCES

1. Pain The Fifth Vital Sign, Canadian Hemophilia Society, 2004,www.hemophilia.ca

2. The Pain Management Book for People with Haemophilia and RelatedBleeding Disorders, Hemophilia Foundation Australia and the WorldFederation of Hemophilia, Treatment of Hemophilia Series, Number 22,

April 2000, www.wfh.org3. All About Hemophilia A Guide for Families, Canadian Hemophilia Society,

2001, www.hemophilia.ca4. Hemophilia Today, Canadian Hemophilia Society, www.hemophilia.ca5. Handbook for Physical Activity Guide, Health Canada, www.hc-sc.gc.ca6. Health Canadas Office of Natural Health Products, www.hc-sc.gc.ca7. Canadian Health Network, funded by Health Canada, www.canadian-health-

network.ca

8. Canadian Health Portal, links to provincial or territorial Ministries of Health,www.pcs-chp.gc.ca

9. NCCAM, the U.S. Federal Governments lead agency for scientific researchon complementary and alternative medicine, www.nccam.nih.gov

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